Telemedicine is more than video and phone visits

During the pandemic, many institutions and small practices were forced to create, purchase or adapt a telemedicine platform on the fly to accommodate their patients, and the success of those efforts varied greatly. A lot of research has analyzed the surge in use, including the implications, ramifications and consequences. Research has also investigated disparities in access, use, quality and outcomes, particularly in terms of socioeconomics and the urban-rural divide.

This area is already rich with story ideas for journalists to localize, but there’s another element to consider if you decide to write about telemedicine on a local or national scale: It’s not just phone calls and video conferencing; text messaging, as a new study shows, can play a vital role that goes beyond appointment reminders and confirmations. Journalists writing about telemedicine might consider exploring whether medical institutions or private practices in their area tried any novel uses of text messaging during the pandemic.

The advantages of text messaging medicine, while it’s more limited in its uses than face-to-face telemedicine visits are, include its asynchronous nature (you don’t have to respond immediately) and its greater accessibility to those with low income or living in rural areas that lack high-speed internet connections.

Key points

Telemedicine use, which exploded during the pandemic, involves a wide range of platforms and media including text messaging.
Text messaging has been used for years to prompt reminders to make, keep or confirm appointments, and get immunized, but it can do more. It can be used to check on symptoms and triage patients, thereby allowing more people to stay home and free up hospital resources for those who need them most.
Text messaging could also be a way to reach underserved groups who lack access to high-speed internet.
Journalists should explore how local medical practices are using text messaging — or why they aren’t — and what the outcomes have been.

Overview of study analyzing texting to triage people with COVID-19

The study, funded by the Patient-Centered Outcomes Research Institute and published in the Annals of Internal Medicine on Nov. 16, analyzed mortality outcomes among people who participated in an automated remote monitoring service for adults who had COVID-19 and were at home. Almost 90% of people with COVID are told to isolate themselves and monitor their symptoms, but some may not recognize when they need to go to the hospital or might fear going. Hospitals, meanwhile, are often overwhelmed during surges, so any patient triaging helps.

To that end, the University of Pennsylvania Health System developed a remote monitoring COVID Watch program, initially in English and then with a Spanish version in May 2020. These were its key features:

Automated texts twice daily asked adults how they felt and if specific symptoms had worsened.
Those who answered “yes” to whether it was getting harder to breathe received a call from a telemedicine clinician within an hour, 24-7.
If patients began feeling worse between check-ins every 12 hours, they could text “worse” to trigger a call.
Daytime clinicians were mainly nurses with nurse practitioner and physician support, and nighttime calls went straight to a nurse practitioner or doctor.
Clinicians could offer advice on managing symptoms, prescribe medications, or recommend patients go to the emergency room.
Patients remained in the program for two weeks after enrolling and could then renew participation for another week.

The study ran from March-November 2020 and involved 3,488 patients using COVID Watch and a control group of 4,377 adults receiving usual care. Here were the key findings:

At 30 days after enrollment in COVID Watch, patients enrolled in the program were less likely to die than those getting usual care: one life was saved for every 400 patients enrolled, even after adjusting for differences in demographics and risk factors.
At 60 days after enrollment, the rate of death among those using COVID Watch, compared to usual care, was 2.5 fewer deaths per 1,000 patients — true for all major racial/ethnic subgroups.
In other words, if 100 out of 10,000 patients receiving usual care died within two months, then only 75 out of 10,000 patients using the service had died.
5% of patients with usual care died outside the hospital; none of those using COVID Watch died outside the hospital, “which is consistent with the interpretation that COVID Watch exerts its effect by increasing vigilance over those at home and efficiently sorting them into those who will benefit from the emergency department and those who will not,” the authors wrote.
Patients using COVID Watch had more telemedicine meetings, emergency room visits, and hospitalizations, and went to the ER sooner than those with usual care.
The lower mortality in those using the service appeared to result from patients going to the hospital sooner when needed.
Interestingly, Black patients were more likely to enroll in COVID Watch than go with usual care.
A substantial limitation is selection bias: patients chose whether to enroll or not, and those who chose to enroll might be more vigilant about their symptoms and more willing to go to the hospital.

Questions journalists might consider asking locally

Have any local practices or hospitals used a similar program?
What’s the cost associated with starting up a program like this?
Is this only useful during a pandemic, or could it become useful during non-pandemic times?
How much of the findings are due to selection bias, and how can you control for that to find out?
How many lives could something like this potentially save when hospitals are over capacity?
Could a program like this reduce disparities in COVID deaths?
Could/does a program like this reduce mortality from other conditions among people who don’t go to the hospital during a pandemic?
Could this program overcome the fear of going to the hospital during a pandemic?